Amphetamine Use Disorders

Michael J. Mancino, M.D.

University of Arkansas for Medical Sciences

© AMSP 2011 1

Substance Use/Problems %

Lifetime Substance Use → → →

• Alcohol: 80

• Cannabinoids: 40

• Cocaine: 15

• Amphetamine: 10

Lifetime Problems

60

50

50

60© AMSP 2011 2

Why Problems Arise• Mimic medical/psych dx

• ↑ symptoms

• Direct side effects

• Occur in patient populations

• Recent ↑ in use© AMSP 2011 3

This Talk Will Review

• History/nature of amphetamines

• Epidemiology

• Problems

• Treatment© AMSP 2011 4

History• 1887- Amphetamine synthesized

• 1919 - Methamphetamine synthesized

• 1930’s – AMPH OTCOTC bronchodilator

• 1937 – AMPH prescription only

• 1939 – WWII troops, factory workers

• 1959 – FDA bans inhalers

• 1970 - AMPH Schedule II© AMSP 2011

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Drug Classification• Depressants:↑sleep, ETOH high, disinhibit

• Cannabinoids → ↓ drive, ↑ appetite

• Opioids → ↓ pain, ↓ cough

• Stimulants → ↑ energy/attention/activity© AMSP 2011 6

Amphetamines• Routes of use

–Oral

–Nasal

–Intravenous

• Amphetamine high short-lived

–Drug half-life = 12-13 hours

–Post high letdown© AMSP 2011

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Amphetamines

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StructureAdrenaline Amphetamine

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Structure → Function• Adrenaline = Epinephrine

• “Fight or flight”

• Bind to sympathetic system

• Mobilize defense system–↑ glucose

–Shift blood© AMSP 2011 10

How Neurons CommunicateNeurotransmitters are:

1. Synthesized in cell

2. Released

3. Bound to post-synaptic receptors

4. Recycled by transporters

5. Broken down by enzymes

6. Bound to pre-synaptic receptors

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2 4

3

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12© AMSP 2011 12

Effect of AMPH at the Synapse

DA-T

DAAMPH

DA-R

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1. AMPH enters in exchange for DA

DA-T

DAAMPH

DA-R

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2. AMPH enters pre-synaptic vesicles

DA-T

DAAMPH

DA-R

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3. ↑ release of DA in pre-synapse

DA-T

DAAMPH

DA-R

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4.↑ DA in pre-synapse and synapse

DA-T

DAAMPH

DA-R

Medical Uses• Narcolepsy: sleep disorder

–Modafinil (Provigil)

–Armodafinil (Nuvigil)

• ADHD: developmental d/o–Amph/d-amphetamine (Adderall)

–Methylphenidate (Ritalin)© AMSP 2011 17

This Talk Will Review

History/nature of amphetamines

• Epidemiology

• Problems

• Treatment© AMSP 2011 18

Epidemiology• US lifetime use 2009 ≈ 10%

–Highest rate age 26-34 (>12%)

–Rate males = females

–Rate 2X white > black

• Past month use ≈ 0.5 %

• Lifetime dependence ≈ 1.5 %© AMSP 2011

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Drug Dependence• Presence of ≥ 3 in 12 months

– Tolerance– Withdrawal– Larger amounts– Desire/attempts to cut down– ↑ time spent– Give up activities– Ongoing use despite problems

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Drug Abuse• Presence of ≥ 1 in 12 months

–Fulfill obligations

–Physically hazardous situations

–Legal consequences

–Interpersonal problems

Never dependent on this drug© AMSP 2011

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This Talk Will Review History/nature of amphetamines

Epidemiology

• Problems

• Treatment© AMSP 2011 22

Amphetamine Problems• Medical

–Overdose–Withdrawal–Other

• Psychiatric–Psychosis–Anxiety/depression

© AMSP 201123

Overdose

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Copyright © 2010 Meth Kills

OD: Sympathetic Symptoms• ↑ heart rate (> 100 beats/min)

• ↑blood pressure (>160 /110)

• ↑ respiratory rate (>30/min)

• ↑ temperature (> 1020 F)

• Dilated pupils

• Seizures© AMSP 2011 25

OD: Sympathetic Symptoms

• Chest pain / heart attack

• Stroke

• Arrhythmias = irregular heart beat

• Muscle rigidity → shock© AMSP 2011 26

OD: Psychological Effects

• Restlessness

• Dizziness

• Irritable/violent

• Insomnia

• Higher doses →

–Suspiciousness

–Stereotypy

–Bruxism

–Punding© AMSP 2011 27

OD Treatment• Basic life support (ABC’s)

• ↑ temp - dantroline (Dantrium): 1-2mg/kg

• Seizures (diazepam): 10mg IV

• ↑ BP- phentolamine (Regitine): 5-15mg

• Chest pains/heart attack

• Urine tox: ID other drugs© AMSP 2011 28

Agitation Treatment• Benzodiazepines

• Diazepam (Valium): 10-30mg PO, 2-10 mg IV 

• Lorazepam (Ativan): 2-4 mg PO, IM, IV

• Hi potency antipsychotics (anticholinergic SE)

• Haloperidol (Haldol): 5-10 mg PO, IM, IV

• Risperidone (Risperdal): 2-4 mg PO

© AMSP 2011 29

Withdrawal• Begins ≥ 2 hrs, peaks day 1-2

• Symptoms opposite intoxication

– Sleepy, depressed, ↓ concentration, ↑ appetite

– Craving

• Symptoms ↓ over 3-4 days

• ↓ concentration/↑ sad last ≥ 2 months

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Other Medical Problems• Infection (contaminated needles)

–Endocarditis (heart valve inflammation)

–Skin abcesses

–HIV → AIDS

• Intranasal → holes in nasal septum

• Heart attack

• Stroke (hemorrhagic or ischemic)© AMSP 2011 31

Psychiatric

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Stimulant Psychosis vs Schizophrenia

Stimulant Psychosis

• Labile mood

• Develops rapidly

• Physical findings

• Resolve days/wk

Schizophrenia

• Bland mood

• Develops slowly

• Rare findings

• Worsen with time© AMSP 2011 33

Treatment • History, physical & labs

• Hospitalization

• Monitor vitals

• Behavioral

• Antipsychotics

• Avoid benzodiazepines

• Drug rehab© AMSP 2011 34

Anxiety• Intoxication (mimic panic attacks)

– ↑ Heart rate, palpitations

– Nervousness, hyperventilation

• Obsessive-compulsive picture

– Take apart / reassemble mechanical objects

– High levels of use© AMSP 2011 35

Depression• Related to withdrawal

• “Atypical depression”

– Impaired mood

– Sleepiness

– Excessive appetite

• Cessation → mood swings wks/mos© AMSP 2011 36

Treatment Depression/Anxiety• Counseling

• Reassurance

• Medication rarely necessary

• Evaluate medical illness

– Heart attack, hyperthyroidism

• Rule out pre-existing disorders 

– Major depression or anxiety

© AMSP 201137

This Talk Will Review History/nature of amphetamines

Epidemiology

Problems

• Treatment© AMSP 2011 38

Rehabilitation Goals• Drug free forever

• Interim goals to reduce

– Use

– HIV risk and other med issues

– Unemployment

– Crime

• Engage in treatment © AMSP 2011 39

Rehabilitation Focus• Engage in treatment

• Support abstinence

• Prevent/reduce relapse

• Life management skills

• Cope with anxiety/stress© AMSP 2011 40

Rehab Tools• Individual & group counseling

• Urine toxicology

• Psychosocial treatments– Contingency management

– Motivational interviewing

– Cognitive behavioral therapy (CBT)

– Self help groups

• Vocational rehab© AMSP 2011 41

Medications

• Other substance use disorders

–Alcohol

–Opiates

• No efficacious meds for AMPH

© AMSP 2011 42

Summary

• Amphetamine structure → action

• Amphetamine use common & serious

• Problems mimic med/psych problems

• Tx required for acute & chronic use

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